PDF HIV/AIDS And The Future Of The Poor, Illiterate And ...

HIV/AIDS And The Future Of The Poor, Illiterate And Marginalized Populations Rajan Gupta

Theoretical Division Los Alamos National Laboratory

Los Alamos, NM 87545, USA rajan@

Introduction:

Today, of the global population of 6.5 billion people about 2 billion have access to modern facilities (food, water, shelter, sanitation, health care, education, jobs), who I characterize as the "haves". Of these 2 billion, roughly 1 billion live in the developed (industrialized) world and the second billion consist of the top 15-20% of the remaining world population. About 3 billion are poor (living under $2 Purchasing Power Parity (PPP) per day) and do not have access to modern facilities.1 Of these, roughly 1 billion people live on less than $1 PPP per day and constitute the extremely poor. The remaining1.5 of the 6.5 billion are in transition between the poor and the haves, i.e., they have access to some but not enough of the modern facilities. These ratios are unprecedented in human history and there are many recent success stories of development at the national level ? Taiwan, South Korea, Singapore and Ireland being the most obvious ? nevertheless, there remains a much larger global need.

The central message of this article is that we must act with a sense of urgency to accelerate the transition from poverty to developed modern societies. The reasons are both humanitarian and strategic ? to preserve global peace, security and prosperity.

In this article2 I would like to first summarize the status of the global burden of HIV/AIDS and then use the fast spread of HIV as an example to draw attention to a much deeper and more fundamental problem ? the very future of the poor ? the 3 billion people living on less than $2 PPP per day. I then discuss the interconnected cycle of threats to the development of the poor and end with a prioritized list of urgently needed interventions and argue that we, for the first time in history, have the resources and the understanding (that it can be done, that it will benefit all, and that it will not decrease the wealth of the "haves") to implement the necessary and needed programs that can remove extreme poverty, if not poverty, by 2025. The purpose of this article is not to apportion blame or point fingers but to highlight the possibility that we can create a global society in which no child is denied the opportunity to develop and be part of the 21st century. If the discussion appears one-sided it is because the developed world has the most to offer and is developing most of the technology while the poor need help.

HIV/AIDS:

In 1981 the world first came face to face with a new virus that destroys the human immune system when five young males checked into hospitals in Los Angeles and other major metropolis in the US with highly compromised immune systems ? the AIDS (Acquired Immune Deficiency Syndrome) patients. Over the next three years researchers worked very hard to decipher the etiology of AIDS, means of transmission, and develop tests for detecting the virus. By April 1984, the teams of Dr. Robert Gallo of the National Cancer Institute, Dr. Luc Montagnier at the

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Pasteur Institute in Paris, and Dr. Jay Levy at the University of California, San Francisco, had identified the cause as a new retrovirus, subsequently named Human Immunodeficiency Virus, or HIV. The first HIV/AIDS antibody test, an ELISA-type test, became available in March 1985. Unfortunately, by that time the CDC had already reported 10,000 cases of HIV/AIDS in the United States, 4,942 deaths and many more were estimated to have been infected. For a timeline of the spread from 1981-88 see

The impact of HIV/AIDS over the next ten year period (1985-95) was devastating. Even though the means of transmission, mainly through unprotected anal and vaginal sex and shared needles by IV drug users, were known very early on, the number of HIV infections grew exponentially. In US alone the numbers grew from about 1000 cases in 1983 to 10,000 cases in 1985 to 100,000 cases in 1989 to 500,000 cases in 1995. Relatives and friends watched loved ones die and the medical community struggled without hope. Doctors could diagnose but could not treat and make whole those infected. Once the ELISA test was discovered they were able to make the blood supply safe, thus stopping the accidental spread in the developed world, but their initial hope of the quick discovery of a vaccine proved unjustified. The number of people dying annually in the developed world due to AIDS continued to rise until 1995 (reaching about 42,000 per year in the US) when triple cocktails of protease inhibitors combined with [non-]nucleoside reverse transcriptase inhibitors proved effective in bringing viral loads to negligible numbers in most patients. These drug cocktails changed the face of HIV/AIDS ? a diagnosis of HIV/AIDS no longer meant imminent death. Unfortunately, these drugs were extremely expensive and toxic and the anti-retroviral therapy (ART), the aggressive form of ART is called HAART for Highly Active Anti-Retroviral Therapy, was available only in the developed world. Tragically, the burden of HIV/AIDS in the developing world has, by and large, continued to mount as if no therapy is known and in many Asian and Sub-Saharan African countries as if even the means of spread and prevention are still unknown. Even though generic manufacturers have brought down the cost of drugs to roughly $150 per person per year, nevertheless, access to ART by the poor remains very limited. The uncontrolled spread of HIV/AIDS amongst the poor continues to highlight the divide in access to health care, education, and empowerment to make safe choices between the haves and the have-nots.

By the end of 2004, roughly 40 million people were estimated to be living with HIV and 30 million had died (). In 2004 alone approximately 5 million new infections and 3 million deaths took place. Large parts of Sub-Saharan Africa are being devastated. In many regions an entire generation has been wiped out leaving grandparents to look after AIDS orphans, many of whom are HIV positive. School, hospital, security and government services are collapsing as trained staff are dying faster than new people can be trained. This need not be the case. HAART has been shown to extend the life of people in both the industrialized and developing world. Even the poorest and totally illiterate people have shown amazing fortitude in dealing with the stigma of coming forward to receive treatment, in tolerating the toxic side effects of the drugs and adhering to the demanding drug regimen. Generic manufacturers in Brazil, India and Thailand have brought down the prices to where we can provide therapy to all those diagnosed and in need (about 10 million) for about $2 billion per year. The major impediments to large-scale administration of HAART continue to be the lack of infrastructure to deliver the medicines and the lack of financial resources (by nations and individuals) to buy the drugs in the first place. Programs in many developing countries

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(Botswana, Brazil, Cambodia, South Africa and Thailand) have shown that the infrastructure and delivery of drugs can be scaled up rapidly if and when drugs are made available. Unfortunately, large pharmaceutical companies holding drug patents, with the support of their governments, continue to delay access to generic versions by the poor by invoking WTO laws on patents and intellectual property rights.

Behavioral changes that would end risky sex and sharing of needles by IV drug users have been very slow. In the US the number of infections crossed the one million mark in June 2005. There continue to be 40-45 thousand new infections annually and most of the spread is in poor minorities (especially black and Hispanic women) and marginalized communities ? gay men and IV drug users. This is an unacceptable burden for the richest and most developed country but dwarfs in comparison to what is happening in the developing world where roughly 90% of the infections (roughly 5 million each year) and 95% of the deaths (roughly 3 million each year) globally due to HIV/AIDS are taking place. It has increasingly become clear that poverty is a major factor in the spread.3 The poor and the marginalized lack information, means and empowerment to protect themselves, and day to day survival (or anonymity in the case of men having sex with men and IV drug users) very often trumps safe behaviors.

Allowing people to suffer and die when medicines are available is undermining attempts to help their communities develop. Knowledge that should be handed down from parent to child is being lost, and children are growing up hungry and without supervision. The demographic impact of HIV/AIDS, killing people in the most productive stages of their lives, makes it unique in its impact on development. The long-term problems posed by AIDS orphans, already numbering 15-20 million, will need more resources to address than those needed to keep their parents alive and productive. The continued fast spread of HIV/AIDS and its devastating impact on families very clearly illustrates how hard it is to break the cycle of poverty for those living without basic provisions of health care, education, and nutrition.

The question I have repeatedly asked myself is ? if we know the means of transmission of HIV (unprotected anal or vaginal sex, infected blood entering one's body mainly through reuse of needles, and from mother to child) and none of these are casual contacts, then why is HIV still spreading? Within the haves the answer is that many people continue to indulge in risky sexual behavior or are slaves to their drug addiction in spite of adequate knowledge of HIV/AIDS. Within the have-nots, poverty, despondency, day to day survival and lack of knowledge, means of protection and empowerment, make behavior change very difficult to achieve. The situation, in a much broader context, was captured amazing succinctly by Gro Harlem Brundtland, who in 2002 as the Director-General of the WHO said4

The world is living dangerously, either because it has little choice or because it is making wrong choices. On the one side are the millions who are dangerously short of the food, water and security they need to live. On the other side are the millions who suffer because they use too much [or are too indulgent]. All of them face high risks of ill-health. To this I will only add one thing which I elaborate on later. The haves, by not helping half the global population that lives on less than $2 (PPP) per day to break the cycle of poverty, are creating dangerous breeding grounds in which exploitation, violence, criminal behavior, terrorism, civil wars, and diseases will continue to fester. Even though the scale of the many problems and their solutions are large and daunting, my contention is that we have the

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knowledge and resources to address them5 6 and, furthermore, I add that we have no choice if we desire global peace, stability and prosperity. What we need is political and social will based on the principle of shared fate.

The first wave of HIV/AIDS has devastated Sub-Saharan Africa. This devastation did not elicit (until after 2000) much response from most people in power or policymakers sensitive to geopolitics. The cynical view was that none of these countries are important geopolitically except for their natural resources, and tapping these does not need large numbers of people. The slightly less cynical view was ? yes we need to help but there is no local infrastructure through which to intervene. Past attempts at infrastructure creation have been failures and since the governments of these countries are corrupt or ineffective or both any help that is provided is abused. So how does one act to help? Fortunately, it is becoming increasingly clear that if the haves intervene at the requisite levels and holistically (as discussed at the end of this article) then the have-nots are able to rise to the challenge, work hard as partners, and are capable of breaking the cycle of poverty within a generation.

The second wave of HIV/AIDS threatens many populous, strategic and militarily powerful nations ? China, India, Russia, Ethiopia and Nigeria ? as cautioned by the US National Intelligence Council and the CIA in its 2001 report7. Recognizing that each of these countries has large populations of have-nots and marginalized people, it becomes clear that under business as usual approach HIV/AIDS will grow rapidly in these countries and if it grows to anything like the scale in Sub-Saharan Africa, that could lead to global instability. So challenges like the Millennium Development Goals, Global Fund for HIV/AIDS, Tuberculosis and Malaria, and I would like to add Kyoto protocol on climate change because natural disasters and climate change affect the poor disproportionately (the New Orleans hurricane Katrina tragedy is a glaring example), have been developed and are increasingly being supported. Assuming that the haves are willing to help the poor stand up so that they can, in time, learn to walk on their own (develop into modern societies) what I would like to do in the rest of the article is provide, based on my work in India, a list of key common threats to this development, and in light of these threats discuss what is the minimum holistic package needed to seed the transition.

It is important to stress, while making the connection between HIV/AIDS and poverty, that poverty is not the only factor. Removing poverty may not be enough to solve the HIV/AIDS problem since risky sexual behavior and IV drug use are prevalent in all socio-economic sectors. Nevertheless, experience from the developed world shows that addressing issues of poverty makes pandemics, at the very least, manageable, i.e., stabilization followed by a decline in the number of yearly infections versus uncontrolled growth. Thus, our primary concern should be to help all people achieve basic human rights and freedoms and simultaneously work to help those prone to making unhealthy choices reduce risk to themselves.

Challenges The Poor Face:

The challenge we face is to provide resources and skills to the poor to jump start their transition to the 21st century. Unfortunately, there are many "sharks and barracudas" that profit from keeping them poor, exploit them, and undermine even the best attempts of very committed and

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innovative people to provide skills and resources to the poor. Principal amongst these sharks and barracudas are

? Despotic and/or corrupt governments ? National and transnational criminals ? Fanatics and terrorists ? Exploitative multinationals The important question is how and why do these sharks and barracudas persist in the modern world? The answers are age old ? through control and ruthless use of military power, through exploiting religious and ethnic differences, and through co-opting unscrupulous governments and influential individuals.

In this article I will not have the time to even begin to discuss bad policies by governments and the control and ruthless use of military power by them for their own self-centered purposes instead of focusing on alleviating poverty. Most people would contend that poor governance, bad policies and lack of security are the key primary factors that have to be addressed and without which nothing else will have long-term impact. This may very well be true, however, I believe that individuals can do a lot on the ground, especially facilitate the creation of a civil society. The issue I wish to highlight is that, today, non-state actors can be equally effective and important agents of destabilization or progress because they have access to significant resources, and some individuals control resources that are larger than the economies of many nations. To discuss the positive possibilities I start by highlighting the need to eliminate a major global problem that severely impacts the poor. This is the control exerted by criminal and exploitative individuals and organizations who amass vast fortunes through what I call rogue economies. These include ? Narcotics ? Alcohol ? Tobacco ? Trafficking in arms, people and human organs ? Trafficking in ill gotten goods (blood diamonds, illegal timber, counterfeit and pirated goods

and medicines, banned animals and their products, etc.)

I refer to these activities using a politically loaded term "rogue economies" because they are large enough to qualify as economies and, while not all are illegal, they have illegal components. They are all insidious, are a health hazard, undermine development, undermine law and order, create mafias, warlords and drug-lords, promote corruption and prevent the formation of a civil society. I contend that as long as these rogue economies persist there will be sharks and barracudas that thrive. Today these sharks and barracudas have global reach and in some cases are richer and more powerful than governments and, in some cases, are the government.

Production and trafficking of narcotics is the prime example of a rogue economy. Even conservative estimates put the money involved at over $500 billion per year.8 The economies, security and development of many nations (the most significant being Columbia, Peru, Bolivia, Mexico, Nigeria, Ukraine, Russia, Tajikistan, Afghanistan, Pakistan, Myanmar, Laos and Thailand) are overwhelmed by the drug trade. Industrialized nations spend hundreds of billions of dollars yearly to try and confront the menace but have had very limited success. Each of the countries mentioned above also illustrates the connection between drug trade, private militias,

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money laundering, lack of development, civil wars and terrorism. In both the industrialized and developing worlds IV drug use is a major factor in the rapid spread of HIV/AIDS. I do not believe that anyone, having given even a moment's thought to this problem, would argue that the illegal drug trade is not a global problem that needs to be addressed with a sense of urgency.

A significant fraction of the adult population (10% is a typical estimate) of many developed nations has a serious alcohol abuse problem. Nevertheless, alcoholism and its consequences for health care, lost productivity, domestic violence, crime and road accidents are treated as an acceptable burden because of the overall prosperity. Social drinking is considered a safety valve against stress and thus a lesser of social evils. Promotion is accepted because it involves an individual's lifestyle regarding a legal activity. In the developing world alcohol abuse has become a nightmarish problem. Anyone with first hand experience of India understands that alcohol is a major impediment to development, especially in rural India. I have not visited any rural community in India where women have not listed it as the number one problem. It is the major cause of domestic violence and financial hardship. Children growing up in alcoholic homes do not have safety nets that can compensate for the stressed and unhealthy home environment and very often grow up without adequate health care, nutrition and education. A detailed analysis of the nexus between narcotics, alcohol abuse and sexually transmitted infections including HIV/AIDS in India and their implication for development and security has been presented in reference9.

The laws on international trade in tobacco baffle me. How is it possible that the US and most of Europe have declared smoking as hazardous to health, banned smoking in public buildings, and are enacting ever more stringent laws against it and yet feel no obligation to ban export of cigarettes? What I would like to advocate is that if Americans (or citizens of any other country) wish to smoke then so be it, but we should not allow export of a health hazard (in the form of finished products like cigarettes, chewing tobacco, and cigars) to continue just because it is profitable. The case against trafficking in arms, people, human organs, exotic species and ill gotten goods is so obvious that I hope it needs no discussion.

The problem we face is that these rogue economies are so entrenched and pervasive and the profit margin is so high that they have defied control. Unfortunately, their impact on the poor continues to be devastating.

What do the poor need to develop? Generalizing from what parents offer to children, I consider the three most important things to be: ? Opportunities and Skills: These require access to heath care, nutrition, education, an

environment that fosters a love for learning, job training, and activities like sports that provide healthy use of leisure time. ? Direction: This requires there be enough role models that lead by example and exemplify the virtues and payback of hard work and goal oriented focus. ? Stable, loving and nurturing environment that provides physical, mental and emotional health and leads to the development of safe behaviors. Rogue economies undermine each of these three. Easily seduced by the possibility of instant and easy gratification and/or money people fail to learn skills valued in the 21st century. The interdependencies between these three developmental goals highlights the need for synergy

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